An Assessment of Histopathological Criteria for Infection in Joint Arthroplasty in Rheumatoid Synovium

Abstract

Intraoperative frozen section is reported to be a reliable means of identifying occult infection for preoperative evaluation of arthroplasty. The aim of this study was to determine whether the reported histopathological criteria--the existence of more than 10 polymorphonuclear cells (PMN) per high-power field--is valuable for determination of infection during the arthroplasty of patients with rheumatoid arthritis (RA). The permanent histological sections of RA synovium were analysed to study the degree of infiltration of PMNs. Furthermore, in order to examine the penetrative distribution of PMNs within the synovial tissues, immunohistochemical staining of PMNs was performed. In addition, the clinical history, from the postoperative period to the present, was investigated in 46 patients (60 joints). The presence of early- and/or late-stage postoperative infection, the development of postoperative fever, the progression of erythrocyte sedimentation rate (ESR) (more than 30 mm per hour) and the changes in CRP (more than 10 mg per litre) were further examined and compared with the histopathological tissue analyses and findings. The results demonstrated the presence of more than five PMNs per high-power field, excluding surface fibrin and inflammatory exudate in at least five separate microscopic fields in 10 joints (16.7%) of nine patients, out of 60 joints of 46 patients, in which no postoperative infection was evident. As to the magnitude of penetrative distribution of PMNs in 10 joints, there was a trend of deepening infiltration among the patients with intensive PMN infiltration. In addition, no development of postoperative fever, CRP or continuous indications of high ESR values were evident in this group. As the existence of more than 10 PMN per high-power field was not absolutely indicative of occult infection, investigation of frozen section during arthroplasty should be carefully managed.

Histopathology in Periprosthetic Joint Infection: When Will the Morphomolecular Diagnosis Be a Reality?

“…Finally, there are two groups of patients in which histology produces a high rate of false positives for diagnosis of infection: patients who undergo a prosthetic replacement and have an underlying inflammatory disease (e.g., rheumatoid arthritis) [ 52 ] and those receiving a prosthetic replacement for a periprosthetic fracture [ 11 , 41 ]. The first group of patients have a persistent neutrophil infiltration in the periprosthetic tissues due to the underlying active disease and not due to prosthetic infection.…”

“…The first group of patients have a persistent neutrophil infiltration in the periprosthetic tissues due to the underlying active disease and not due to prosthetic infection. Kataoka et al [ 52 ] studied synovial tissue in 60 joints from rheumatoid arthritis patients at the time of the placement of an arthroplasty and found 10 cases with more than five PMNs per high-power field. They concluded that PMNs in the rheumatoid synovium were a common microscopic finding and that the presence of more than five PMNs per high-power field in the rheumatoid synovium was not necessarily consistent with infection.…”

Synovectomy, debridement, and continuous irrigation for infected total knee arthroplasty

“…A causative microorganism was detected in eight joints (Table 1). In the other two joints, the diagnosis was based on the histopathological examination of synovial membrane that showed more than ten granulocytes in a high-power field [8].…”